Integrated Care Social Worker

CenterWell • El Paso, TX

16h • Hybrid

About The Position

The Integrated Care Social Worker supports the organization's highest risk patient population, representing approximately the top 5% of patients with the greatest medical, functional, behavioral, and social complexity. By working closely with integrated care team members, you will serve as the primary source for complex psychosocial needs, identifying and addressing social, environmental, and behavioral barriers that interfere with care engagement and safe transitions across settings. The Integrated Social Worker provides specialized support for patients whose outcomes and utilization are impacted by psychosocial complexity, such as social instability, financial hardship, behavioral health concerns, caregiver strain, or difficulty navigating healthcare and social services. You will understand department, segment, and organizational strategy and operating goals, including their linkages to related areas. You will report to a Care Integration Team Manager.

Requirements

• Active and unrestricted Licensed Master Social Worker (LMSW) in the state of Texas
• Bilingual in English and Spanish (with the ability to read, write and speak in both languages)
• 2+ years of clinical social work experience, including care coordination across complex clinical and community settings
• Experience working with high-risk, medically complex, or socially vulnerable populations
• Knowledge of health-related social needs (HRSNs) and social determinants of health (SDOH)

Nice To Haves

• Experience addressing HRSNs and SDOH (e.g., housing, food insecurity, transportation, financial strain)
• Background in behavioral health support and working with psychosocial complexity
• Experience with seniors, medically complex patients, or population health/value-based care models

Responsibilities

• Conduct comprehensive psychosocial assessments to identify barriers such as housing, food insecurity, transportation, financial stress, safety concerns, caregiver capacity, mental health, substance use, and health literacy.
• Facilitate access to high-barrier services (e.g., long-term care, housing, community resources), assist with referrals and applications, and coordinate across agencies to close gaps in care.
• Provide short-term, supportive interventions, screen for behavioral health or substance use concerns, and connect patients to appropriate services.
• Partner with Care Coaches following hospitalizations or ED visits to address psychosocial barriers and reduce avoidable readmissions.
• Work with Care Coaches and PCPs to integrate care plans, participate in high-risk rounds, and serve as the program's primary resource for complex psychosocial needs.

Benefits

• medical
• dental
• vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level